Summary
The coding specialist, utilizing coding skills and clinical knowledge, reviews the medical record. Accurate ICD-10 diagnosis and CPT procedure codes are then assigned based on the documentation in the medical record, which directly impacts reimbursement. The specialist queries the clinician when needed for clarification of the documentation.
Responsibilities
(60%) Assign accurate ICD-CM diagnosis and CPT codes in a timely manner for all appropriate encounters using CMS and American Hospital Guidelines, CPT Assistant, and following AHIMA Code of Ethics.
(30%) Utilize clinical knowledge to interact with physicians/providers regularly to assist in improving documentation within the medical record to accurately reflect the severity of illness and level of care provided.
(10%) Demonstrate willingness to participate in continuing education to enhance coding knowledge.
Other Duties And Responsibilities
Meet established productivity guidelines.
Other duties as assigned.
MyMichigan Health is a technology-driven organization and employees must demonstrate competency in Microsoft Windows.
Employees may be required to participate in further learning opportunities offered by MyMichigan Health.
Certifications and Licensures
Fingerprinting (FINGERPRIN)
Reg Health Information Tech (RHIT) – Effective October 1, 2013, new hires must be RHIA or RHIT eligible, successfully complete the certification exam within six (6) months of hire, and maintain the certification to meet the position requirements.
Registered Health Info Analyst (RHIA)
Employees can have either RHIT or RHIA certification.
Required Education
Associate’s Degree in Health Information Technology required.
Experience, Training And Skills
Coding experience from an AHIMA-approved internship required or successful completion of an independent study program offered by AHIMA.
Knowledge of medical terminology and anatomy preferred.
Written, oral, organizational, and interpersonal skills needed to communicate successfully.
Physical/Mental Requirements And Typical Working Conditions
Exposure to stressful situations, including public contact, trauma, grief, and death.
Able to wear personal protective equipment that includes latex materials or appropriate substitutes if required.
Must be able to move freely about the facility with or without an assisted device and perform the functions of the job as outlined.
Overall vision and hearing are necessary, with or without assisted devices.
Frequently required to sit, stand, or walk for long periods; may need frequent postural changes such as stooping, kneeling, or crouching.
Exposure to bloodborne pathogens and other potentially infectious material; must follow MyMichigan Health bloodborne pathogen and TB testing as required.
Ability to handle multiple tasks, work independently, maintain regular and predictable attendance, and stay awake.
Overall dexterity required, including handling, reaching, grasping, fingering, and feeling; may involve repetitive movements.
Physical Demand Level: Sedentary. Must occasionally (0-33% of the workday) lift or carry 0-10 lbs.
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